State finds fault in Erie County jail death

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The Erie County Holding Center. Photo by Garrett Looker.

The New York Commission of Correction has faulted medical care in the Erie County Holding Center and ordered the county Legislature to review the 2021 death of an inmate whose cancer went undiagnosed.

 James Ellis, 58 and locked up for a parole violation, may have died no matter what, the commission found in a March 27 report. But someone should have called a doctor before he was found unresponsive and taken to a hospital, where he was pronounced dead on Nov. 30, 2021.

Ellis lost 15 pounds while incarcerated for nine weeks and complained that drugs given to reduce excess stomach acid didn’t curb his vomiting. At sick calls on the two days preceding his death, medical staff at the jail twice reported that Ellis’ lungs were clear. An autopsy found Ellis lungs were swollen by fluid with bronchopneumonia present and the right lung marked by a necrotic abscess that signaled weeks of growing infection, the commission reported.

The board questioned the credibility of staff who reported that Ellis’ lungs were clear, the board wrote in its report.

“The medical review [board] opines that there was a failure by medical staff to properly assess, failure to notify and consult with a physician and a grossly missed diagnosis,” the commission wrote.

The commission wrote that the jail’s medical staff should conduct an independent peer review of Ellis’ death. Peer review, which would involve medical experts with no ties to the jail, should determine why Ellis wasn’t seen by a doctor, why no one recognized that he’d lost weight, why he continued getting drugs that didn’t resolve his vomiting, and how medical staff documented that his lungs were clear despite bronchopneumonia and an abscess being found at autopsy, the commission wrote.

The board also questioned the county medical examiner’s conclusion, made without microscopic tissue studies, that Ellis had succumbed to cancer that spread from his stomach. The medical examiner reviewed Ellis’ case at the board’s request, according to the commission report, but did not change findings.

A January response from the sheriff’s office to the commission’s preliminary findings didn’t satisfy the state.

“The quality of care issues identified by the medical review board were not specifically addressed in the response,” the commission wrote. “The medical review board remains affirmed in their findings and the identified issues in the case.”

Sheriff John Garcia refused interview requests from Investigative Post. 

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The state commission also told April Baskin, county Legislature chairwoman, to review findings in the Ellis case and examine the fitness of jail health care providers. Baskin said she’ll ask the county Corrections Specialist Advisory Board to review Ellis’ case as well as the November death of William Hager in the county correctional facility in Alden. An autopsy showed that Hager, a homeless schizophrenic, died from water intoxication.

“They are professionals who have worked in the space of corrections,” Baskin said. “Once they advise us on their thoughts, to me, the next step is for the Legislature, or me, to have a conversation with the office of the sheriff.”

Three county inmates died during the last five months of 2023, according to a state attorney general database. The advisory board appointed by the Legislature didn’t discuss any jail deaths during monthly meetings in February and March of this year.

Baskin said she wasn’t familiar with Shaun Humphrey, who died last August after a struggle with holding center jailers assigned to handcuff him. The state attorney general launched a full investigation in February, when the medical examiner determined that Humphrey died from positional asphyxiation and ruled his death a homicide.

Reminded of circumstances surrounding Humphrey’s death, Baskin told Investigative Post that she’ll ask the county’s advisory board to look into every jail death that’s occurred over the past four years.

“They’re all blending together,” Baskin said. 

Since 2005, 38 county inmates have died, including six since Garcia took office in 2022. Between April 2021 and the end of last year, Erie County jails, with seven deaths, have been deadlier than any other county lockups of similar size in New York state, according to statistics kept by the state attorney general.

Jail lawsuits

A jury this month awarded $95 million to the family of Richard Metcalf, who died in 2012 after holding center jailers put a pillow case and spit mask over his head while he was lying prone. The state commission found that Metcalf suffocated and questioned why jailers didn’t send him to a psychiatrist despite obvious mental illness.

In March, the county Legislature agreed to pay $1.2 million to settle a lawsuit filed by representatives of David Glenn, who attempted to hang himself in 2012 and now lives in a nursing home, with annual care costs surpassing $400,000, according to the lawsuit. Glenn had repeatedly asked to see a mental health counselor before attempting suicide, according to documents in the lawsuit, but got scant attention.

“My mind is on overload,” Glenn wrote in a message to counselor Ernest Donalson the day before his suicide attempt. “I’ve asked for help every day and been refused. If you ever find someone you love, hold on to them, and even if family is pain in the ass, love them, never let them go. How good God is.”

After Glenn’s suicide attempt, Donalson resigned when a supervisor found messages in his office from as many as four inmates whose requests for mental health assistance had gone unanswered, according to depositions in the lawsuit. Donalson, a provisional county employee, held a limited mental health counseling permit from the state but had not taken an exam required for a mental health counseling license.

At least four lawsuits are pending over deaths of county inmates, with plaintiffs alleging that inadequate mental health or medical care contributed to deaths.

The mother of India Cummings sued in 2017, the year after her daughter died from renal failure after 17 days in the holding center. In 2018, the commission reported that she was exhibiting signs of mental illness, may have been deprived of water and had a broken arm that wasn’t adequately treated. The medical care Cummings received “was so grossly incompetent and inadequate as to shock the conscience,” the commission wrote.

The family of Robert Ingalsbe, who hung himself in 2019 while in the holding center, sued the county in 2020, saying that jailers knew or should have known that he was suicidal and did not  properly monitor him.

The sister of Connell Burrell, a diabetic who died in 2019 after choking on a peanut butter sandwich, sued in 2020. The county fired a nurse who ordered the sandwich for Burrell, who was semi-conscious from low blood sugar. The state Commission of Correction ruled the death preventable. As with Ellis, the commission told the county Legislature to conduct an inquiry into the fitness of jail health care providers.

The family of Sean Riordan, a holding center inmate, sued the county, alleging deficient medical care, after he died in 2022 while going through alcohol withdrawal. The county medical examiner’s office criticized the sheriff’s office in an autopsy report, saying that Riordan received inadequate care at the holding center.

Families of at least three other inmates who’ve died since 2022 have retained attorneys and are contemplating lawsuits. 

Cases include:

• Humphrey, the holding center inmate whose August death prompted an investigation by the state attorney general after the medical examiner’s office reported that he died from positional asphyxiation and ruled the death a homicide.
• Hager, whose siblings ask why jailers at the Alden correctional facility didn’t notice that he was drinking a fatal amount of water.
• William Henley, who died in 2022 after being booked into the holding center. County prosecutors say that he died from a neck fracture sustained before he was incarcerated. Ryan Johnsen, attorney for the estate, said that he expects to sue the county.

 “They did a nice job of trying to blame it on everybody but themselves,” Johnsen said.

Bruce Rushton